SPECIAL
REVIEWS
JOSEPH STOKES, JR.
M.D.,
EditorWHY
SCHOOL
HEALTH
SERVICE?
By GEORGE M. WHEATLEY,
M.D.,
M.P.H.
New York City
T
HERE has been a marked change in our concept of the term ‘‘school health service.”Early activities in this field were almost wholly devoted to the control of
com-municable disease. Today, thanks to immunization, the antibiotic drugs and health
edu-cation, most of the old enemies of child health have been conquered. As a result, the years that a child spends in school have been made the healthiest period of life, when appraised by the crude measure of mortality.’
Why then school health service ? Let me first define what I mean by this term. It com-prises health supervision of the school child by educators, public health nurses and school physicians for case-finding and health guidance. At no other time of life is the child or family so readily available for preventive medical service and health education. Public health cannot afford to neglect this ready access to so large a segment of the population-actually more than 20 million persons.
Entrance to kindergarten and first grade is perhaps the most valuable of these
oppor-tunities. For all too many children, this is the first health examination since the first year
of life. Habit disorders or physical defects which have developed in the preschool years
can be brought to light and treatment advised.
A convincing demonstration of the value of a good medical examination at this time of life occurred recently when I was instructing a group of fourth year medical students. As part of their pediatric training, they visited a school to do some examinations under supervision. Their boredom at the prospect of examining a bunch of well children was
evident. Each student was assigned a youngster entering school for the first time. They
were told to interview the parent and then to make a careful examination. Very soon one of the students returned in much excitement and reported the discovery of a large hydrocele and scrotal hernia. The interview with the mother revealed that the defect had been noticed for some time but she did not believe anything could be done about it.
This is not an isolated situation. For example, Hardy,2 in a recent study of children entering school, discovered that 75% needed further medical attention, that almost the same percentage had dietary, rest and related problems requiring family health guidance. We know that certain health problems are to be anticipated as children advance in school. For instance, vision, hearing and speech disorders must be looked for and corrected. Fortunately, rapid, validated screening tests can be employed for their detection
at systematic intervals during school life. Dental needs are likewise serious and can best be met at this time.
At this time, too, rheumatic heart disease also commonly begins. The school is a stra-tegic place to locate possible cases and to aid in maintaining the continuity of health supervision which these children especially need.
Dr. Wheatley is Third Vice President, Metropolitan Life Insurance Company, New York, N.Y.
Presented at the Section on Preventive Medicine and Industrial Hygiene at the Annual Meeting of the American Medical Association, Atlantic City, N.J., June 10, 1949.
(Received for publication Oct. 20, 1949.)
While healthy emotional patterns and good habits of eating, sleeping and general hygiene should have\ been established in infancy and the preschool period, nevertheless, much can and should be done during school life to foster these fundamentals for a healthy maturity. This is why it is essential for teachers to be a part of the health service pro-gram. Their day to day observation and teaching are vastly more influential in achieving
a sound body and a sound mind than the occasional efforts of the physician and nurse. The physically handicapped child needs particular attention because in some instances further treatment may promise improvement or even cure of the condition. In all cases the school has a special responsibility to appraise the child’s potentialities and do all that is reasonable to enable the child to attain his full capacity for work and play.
These are some of the major reasons why school health service is an essential com-ponent of the public health program of the community. It is preventive medical service for a fifth of the population.
The strong current of public interest in the health of the school child following World War II is expressed in the National School Health Services Act of 1949 which was re-cently passed by the Senate without a dissenting vote. This legislation, if enacted, provides 35 million dollars to assist states to improve school services.
This represents a substantial increase in expenditures. States now spend about $24,600,000 for health service in schools ; most of this money is spent in cities. There is great variation between cities in the expenditure per pupil.3 For example, Newark, N.J., spends $5.33, New York City $2.1 1, Los Angeles $2.74, Pittsburgh $2.94, Chi-cago $.56, and Detroit $.17. The new legislation leaves the development of the program largely up to the individual states. Are the states prepared to spend this additional money wisely ? Medical advice and guidance is needed at the state level and all along the line.
In view of the increasing interest and the prospect of substantial funds to support further work, it is your duty as a physician to concern yourself with this problem. To help you appraise your local service the following questions and comments may be
helpful.
1. Is existing legislation in the state compatible with the development of a medically
sound program?
Approximately three fourths of the states provide for physical examinations or inspec-tions of school children, Many of these laws are obsolete. Some for instance may forbid clothing to be removed, others require a medical examination of every child every year or require that the examination be done by some other individual as, for example, the teacher, principal or school nurse.
With respect to administrative control, some appreciation of the variation which pre-vails is seen in the following table based on the recent survey of child health services by the American Academy of Pediatrics.4
Agencies giving school medical service
No. Percent Official education 1,271 45 Official health 1,173 41
Joint education and health 323 11
In general, at the local level, education authorities provide the service in urban locali-ties and health agencies are responsible in rural areas.
2. Is the relationship between the educatkn
and
health department conducive to the operation of an effective health service?Cooperation between the departments of health and education at the federal, state and local levels is a basic requirement for a good school health service. Fortunately, this is better appreciated today than it was a few years ago. Each department has an important contribution to make to the ‘total program. On the one hand, the health department is the official legally constituted agency with responsibility for the health of the entire
com-munity. The health department has the technical personnel and a better perspective of the
community’s health to enable it to judge best how to spend the taxpayer’s health dollars
most productively. On the other hand, the education department is legally responsible for the supervision of children in its care throughout the school day. It has the technical personnel and the responsibility for their education. Education departments usually can secure a more adequate budget for school health work than can health departments. Health departments are of more recent origin and other parts of its program compete with school health for tax funds. The money necessary for the school health service
repre-sents a smaller item in the total education department budget than in the health department
budget. In the latter department, school health service is often the largest single item and when the health department has to reduce expenses, it is likely to cut the school health service budget first because it has the larger portion.
School health authorities are agreed that neither the health department nor education department alone can do the job of providing good school health services.5 Team work or an active partnership is required because each has a definite role to play. In a number of states we now have interdepartmental committees or councils which bring the two departments together for joint planning and operation. Thus duplication of administra-tive personnel is avoided and a uniform program can be achieved. This makes for better understanding between the two departments and provides a more intelligent as well as more efficient school health program. Such councils or committees have a place at all levels-national, state and local.
The School Health Services Act, if enacted, would require that state education and health
authorities jointly prepare the state plan in order to qualify for federal aid.
3. is there an adequate supply of public health nurses serving schools in order to follow-up children with health problems?
Adequate nursing service must be provided for the follow-up of children with health problems and the other manifold activities of the school nurse. She is the only one who devotes all her time in the school to the care of the child’s health, Yet in planning school health services, her key role is sometimes overlooked.
nursing time than this built up an overwhelming load of medical problems for follow-up. The most efficient results are usually obtained by the generalized public health nurse who works part-time in the school and part-time in her district. Full-time nurses may be necessary in large schools.
4. Are health services integrated with health education?
One of the prime purposes of school health service is to create in the child an under-standing and desire for preventive medical service. Unfortunately, this educational objec-tive has rarely been achieved by the usual school medical examination. All too fre-quently haste and superficiality make it a bad educational experience for the child. We have a responsibility as physicians to help to improve the quality of the school health examination and to make it a truly satisfactory learning experience. While it is not appro-priate to make the examination a searching diagnostic procedure, it should be done with as much care as to command medical respect and be of educational value.
With the parent present at the examination, with stress on adequate history taking, with emphasis on interpretation of his findings to parent, nurse and teacher, and careful attention to planning after-care of the child, the school physician can meet his educational opportunities and responsibilities. Under these conditions, he will use facts coming from the teacher and the home which relate to the educational, emotional and social problems
of the child.
Several recent contributions on the school health program recognize the importance of defining the functions and education of school health
A committee of a medical society in cooperation with health and education departments might plan a program of refresher courses about child growth and development, com-mon medical problems in children-especially nose and throat conditions, allergy, endo-crinology, rheumatic fever and mental hygiene.9
5. Is there competent supervision of the program?
The professional personnel doing school work need the leadership and guidance which good professional supervision can give. Except for a few urban communities, this type of supervision does not exist at the local level. The supervision which now exists in state health and education departments should be strengthened. Where supervision does not now exist, it could be provided most economically and competently through health depart-ments employing qualified full-time personnel who have training in pediatrics and school health service. This will aid materially to integrate the school health services with the entire child health program of the community.
6. Does the treatment aspect of the program need strengthening?
The main objective underlying the school health service is to see that something is done about those children who have health problems. The National School Health Service Act would enable states to provide funds not only for diagnostic service but for treatment. The amount of funds made available will put a practical limitation on this feature. It
is logical to urge that the funds be used for vision, hearing and speech disorders which will obviously affect the learning process. State funds should be spent only for the treat-ment of those children who would otherwise not receive care.
service is to develop closer relationships and better understanding between practicing physicians and those administering school health service.
Many physicians fail to realize that the health service is a care-finding and referral agency for them. The practitioner should know that the school health service not only refers patients to him but could perhaps aid him both in diagnosis and follow-up and, in
special ci rcumstances, even treatment.
-Industry has this same problem. Several industries have taken the initiative to solve it. For example, General Motors has conducted a series of dinner meetings in the cities where they maintain large industrial establishments.b0 Physicians who treat many of the plant workers are invited to hear about the industrial medical department’s policies and problems. Visits to the plant are encouraged to see the working operations and to learn some of the working hazards at first hand. These meetings have been very successful in improving the relationship between the plant health service and the community medical facilities.
The follow-up will be strengthened by creating confidence on the part of the practi-tioner in the school’s medical findings.
Many schools are using ineffective, crude methods for the detection of vision and
hearing defects. Present technics should be carefully studied in relation to recommended
procedures. For example, on vision testing the National Society for the Prevention of Blindness has an excellent guide.”
Any procedure to be used for the mass testing of school children for a possible defect should be reviewed and approved by a local medical committee.
The diagnosis and treatment of many of the conditions found in school children, for example, vision and hearing defects, rheumatic fever and heart disease, call for special pro. fessional training and experience. In rural areas specialists in these fields often are not avail-able. In some communities children suspected of heart disease or rheumatic fever are referred by school physicians to a children’s cardiologist employed by the schools. This service is provided with the approval of the medical society and is similar to diagnostic service provided by health departments for tuberculosis and some other diseases. By this careful procedure, more accurate diagnosis for a serious condition is assured and
modifi-cation of the school program can be based on a clearer understanding of the child’s
potentialities. This service should be made available to the practicing physician.
Health supervision is too large a task for the school to do alone. The school should do screening and periodic health examination and health education. The best health educa-tion is to teach personal responsibility for health. Children and their parents should learn through the school health service to depend upon the personal physician and dentists not only for treatment, but for supervision of the well child. Many more children would be examined by their own physicians and dentists if schools made this a policy.
Obviously these questions, however important from a medical and administrative point of view, do not raise all the issues involved in the operation of school health service. A comprehensive outline of policies relating to the entire school health program will be found in ‘‘Suggested School Health Policies” published by the Committee on School
Health Policies of the National Conference for Cooperation in Health Education.
under-One Madison Avenue
standing of the vital importance of health supervision. If this is made an effective edu-cational experience, the child and other members of the family are likely to understand its importance as a health safeguard throughout life. This is the essence of preventive medicine.
REFERENCEs
1. Statistical Bulletin, New York, Metropolitan Life Insurance Company, April 1949.
2. Hardy, Martha C., Study of health needs of Chicago children, Social Service Rev. 19:201, 1945.
3. Maxwell, Cyrus H., U. S. Office of Education, personal communication to the author. Tentative
figures as reported by Superintendents of Schools to the Office of Education.
4. Child Health Services and Pediatric Education, American Academy of Pediatrics, New York,
The Commonwealth Fund, 1949, p. 270.
5. Suggested School Health Policies, Health Education Council, New York, 1946.
6. Nyswander, Dorothy B., Solving School Health Problems, New York, Commonwealth Fund,
1942.
7. Educational Qualifications of School Physicians, Am. J. Pub. Health 34:977, 1944.
8. School Administrator, Physician and Nurse in School Health Program, Monograph 1 3, New
York, Metropolitan Life Insurance Company, 1946.
9. Wheatley, G. M., Physician and school medical services, New England J. Med. 236:205, 1947.
10. Selby, C., General Motors Corporation, personal communication to the author.
I 1. Guide for Eye Inspection and Vision Testing, New York, National Society for the Prevention
